<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_patient_char_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_patient_char_id" data-rule="required" data-source="presentation/patient/char/index" class="form-control selectpage form-control" name="row[presentation_patient_char_id]" type="text" value="{$row.presentation_patient_char_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Meddra_version_for_autopsy_determined_causes_of_death')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-meddra_version_for_autopsy_determined_causes_of_death" class="form-control form-control" name="row[meddra_version_for_autopsy_determined_causes_of_death]" type="number" value="{$row.meddra_version_for_autopsy_determined_causes_of_death}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Autopsy-determined_causes_of_death_meddra_code')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-autopsy_determined_causes_of_death_meddra_code"
                   class="form-control  selectpage form-control"
                   data-source="meddra/index" data-show-field="en" data-show-field="en" data-primary-key="code"
                   name="row[autopsy_determined_causes_of_death_meddra_code]" type="text" value="{$row.autopsy_determined_causes_of_death_meddra_code}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Autopsy-determined_causes_of_death_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-autopsy_determined_causes_of_death_free_text" cols="60" rows="5" data-rule="" class="form-control" name="row[autopsy_determined_causes_of_death_free_text]">{$row.autopsy_determined_causes_of_death_free_text}</textarea>
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
